International Journal of Care Coordination

The management of care of chronic obstructive pulmonary disease improved over the last years but is still very complex. Both over- and underdiagnosis are often reported and misclassification of disease severity is common. Differentiating between chronic obstructive pulmonary disease, asthma and asthma-chronic obstructive pulmonary disease overlap syndrome remains difficult. Much is known about the effectiveness of treatment approaches in chronic obstructive pulmonary disease, but patients are often not treated according to the guidelines, and we need more evidence on effectiveness in phenotypes of chronic obstructive pulmonary disease. Care coordination is of great importance and can help to further improve care for chronic obstructive pulmonary disease patients. Pulmonary rehabilitation and self-management are considered important aspects of chronic obstructive pulmonary disease care. In our opinion, there is a major role for eHealth to improve coordination of care of chronic obstructive pulmonary disease.

The patient-centred or ‘partnership’ approach to delivering care is widely acknowledged as a key feature of high-quality health care systems. The aims of patient-centred care are to encourage people to become active participants in health care decisions, and to act in partnership with them in a way that is respectful of and responsive to their needs, values and preferences. Integrated systems offer an ideal platform to optimise patient-centred care, given their focus on structures and processes that position patients at the centre, rather than the margins of health decision making. The Gold Coast Integrated Care program in Queensland, Australia, embodies the patient-centred approach in providing an alternative to hospital-centric services and better coordination of care for those with complex and chronic conditions. Multidisciplinary teams based in a Coordination Centre collaborate with the patient and primary care practitioner (General Practitioner) to undertake a holistic assessment of needs and risks that are managed and monitored through a shared health information system. This model is transformative for future services in enabling patient-centred, cost-effective, reliable and robust care for those with complex and/or chronic diseases.

Understanding how health care organizations can achieve care coordination internally is essential because it is difficult to achieve, but essential for high-quality and efficient health care delivery. This article offers an answer by providing a synthesis of knowledge about coordination from organization theory, where coordination is a central research topic. The article focuses on intra-organizational coordination, which is challenging especially across boundaries such as departments or professions. It provides an overview of the classic coordination mechanisms, e.g., standardization of work processes, but also of recent insights that have identified the conditions that are required to achieve coordination, and how these conditions can be provided by formal mechanisms, such as standardization, but also informally by drawing on features of the emerging situation. Such research highlights the contribution of, e.g., routines like those guided by care pathways or of artifacts like displays. The coordination insights are also discussed as regards inter-organizational care coordination.